APRIL 2025 Sense Holiday Camps Intake Form & Client Service Agreement

How did you hear about Sense Therapies? *

Participant First & Preferred Name : *

Participant Last Name *

Participant D.O.B *

Pronouns

Primary Carer/Guardian First Name *

Primary Carer/Guardian Surname *

Email Address *

Mobile / Phone Number *

Relationship to Participant *

Street Address *

Address line one *

City *

State *

Postcode *

Secondary Contact - First & Surname *

Secondary Contact - Email *

Secondary Contact - Mobile *

Secondary Contact - Relationship to Participant *

Sense Girls Group- MEET & PICK UP: Sense Therapies Clinic, Bulli

Monday 14.04.2025 - Sense GIRLS GROUP - 10am - 12pm COST : $240 **FULL **

Sense Robotics - MEET & PICK UP : Corrimal Community Centre, Short Street, Corrimal

Tuesday 15.04.2025 - Sense ROBOTICS - 5yrs-7yrs - 9:30am - 11:30am COST : $325 Tuesday 15.04.2025 - Sense ROBOTICS - 8yrs+ - 12:20pm - 2:30pm COST : $325 **FULL ** WAITLIST ONLY**

Sense Adventure Day - MEET & PICK UP : James Oates Reserve, 154 Charles Avenue, Minnamurra

Wednesday 16.04.2025 - Sense ADVENTURE DAY - 10yrs+ 9:30am - COST : $600 - (BBQ LUNCH PROVIDED)

Special Dietary Requirements &/or Allergies *

Sense Surf - MEET & PICK UP : South Sandon Beach, Bulli

Thursday 17.04.2025 - SURF 5yrs-7yrs - 9:30am - 11:30am COST :$325 Thursday 17.04.2025 - SURF 8yrs+ - 12:20pm - 2:30pm COST :$325 **FULL ** WAITLIST ONLY**

What would you like the Participant gain from partaking in Sense Therapies Groups? e.g. Social, Gross motor, Emotional Regulation, Sensory Processing skills etc OR CURRENT PARTICIPANT *

What would you like our Therapy Team to know about the Participant? OR CURRENT PARTICIPANT *

Do we need to be aware of any risks? e.g. allergies, seizures, tendency to abscond or become aggressive if the demand is too high? Please note any triggers you are aware of OR CURRENT PARTICIPANT *

How can we best support/encourage the Participant? OR CURRENT PARTICIPANT *

Are there any diagnoses you would like us to consider in how we plan the sessions? OR CURRENT PARTICIPANT *

What are the Participant's Goals in relation to this Program? OR CURRENT PARTICIPANT *Attach copy of current NDIS Plan - if applicable (optional) - see end of this form

Is there anything the Participant would prefer NOT to partake in? *

NDIS Number - ENSURE DETAILS CORRECT & COMPLETE (If applicable) *

Where to email Invoices : Plan Manager or Participant/Guardian's email *

NDIS Plan Start Date - ENSURE DETAILS CORRECT & COMPLETE (If applicable) *

NDIS Plan End Date - ENSURE DETAILS CORRECT & COMPLETE (If applicable) *

PAYMENT - note : ALL NON-Plan Managed Participants must make either make payment on the day, direct debit (NOTE : out-of-clinic activities must be paid on invoice) *

NDIS Plan ManagedNDIS Self Managed Plan - SEE ABOVEPrivate Health Insurance - SEE ABOVESelf Funded (out of pocket) - SEE ABOVE

DIRECT DEBIT/AUTO-PAYMENT – Available to all NON-NDIS Plan Managed Participants. As invoices are payable on issue, Sense Therapies use a Direct Debit system as preference. Session payments are processed after each session. Payment receipts are emailed & can then be used to lodged/claimed as you wish. Please speak with our Admin Team to provide your details either by email, SMS or phone call. *

YesNoN/A - I am Plan Managed

PROGRAMS OF SUPPORT & CANCELLATIONS

All Sense Team Sports, Term Groups & Holiday Activities including Camps are goal orientated, skill based & delivered as Programs of Support.

Programs of Support are delivered as intensive group therapy for a specific period range (no longer than 12 weeks) with a definite start and finish date.

The inclusive period for each Group/Activity offered by Sense Therapies is detailed in the individual Intake Forms, Confirmations & Itinerary communications – prior to commencement.

In acceptance of participation in Programs of Support Participants agree to be charged for the service provided, regardless of attendance/non attendance - as long as the provider had the capacity to deliver the support/activity (or an alternative) was delivered.

Through utilising the Program of Support model, we can both maximise therapeutic benefit and ensure fair pricing for all Participants. (as per NDIS Price Guide).

Participants must notify Sense Therapies of withdrawl from the Program of Support seven (7) business days PRIOR to the commencement date of each individual camp day confirmed otherwise the Participant agrees 100% of the total fee of Holiday Camp period is payable, regardless of attendance.

**Programs of Support may be covered under the NDIS Capacity Building OT Group rate, provided the Participant has the allocated funding. As individual NDIS Plans differ, we suggest checking that the correct funding is available in the Participant's Plan prior to signing up**

*

INJURY WAIVER

I give permission for the Participant to partake in Sense Therapies Group Program/s. I understand every effort will be made by Sense Therapies to minimise the possibility of injury, I understand some degree of risk remains inherent in participation in the program/s. I understand I am responsible for remaining present (or close by, as agreed) during sessions & ensuring the Participant's safety.

NOTE : This waiver applies to all individuals, including the listed Participant, who are involved/partaking in any way with Sense Therapies activities, whether on or off the premises.

*

Do you give permission for Images, Video and/or Audio of the Participant be utilised on Social Media and Public Platforms? I understand there is no time or geographical limit on the validity of my permission. *

YesNo

FINANCIAL GAINS WAIVER
I understand that the Participant & any associates, including myself, waive all rights to all royalties & related financial related domains. *

Primary Carer/Guardian Signature : *

Draw signature|Type signatureClear

Date of Submission *